Provider Demographics
NPI:1447374509
Name:DURHAM, DEWAYNE (DPO)
Entity type:Individual
Prefix:MR
First Name:DEWAYNE
Middle Name:
Last Name:DURHAM
Suffix:
Gender:M
Credentials:DPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 MILLSTONE DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6859
Mailing Address - Country:US
Mailing Address - Phone:423-238-6821
Mailing Address - Fax:
Practice Address - Street 1:7002 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1715
Practice Address - Country:US
Practice Address - Phone:423-499-0810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0844156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician